From the Guidelines
Surgery is recommended for aortic root dilatation of ≥50 mm in patients with bicuspid aortic valve.
Key Recommendations
- The European Heart Journal guidelines 1 provide clear recommendations for the management of bicuspid aortic valve-associated aortopathy.
- Aortic diameter ≥50 mm is the recommended threshold for surgical intervention in patients with bicuspid aortopathy of the root phenotype.
- For other phenotypes, surgery is recommended when the maximum aortic diameter is ≥55 mm.
- Key considerations for surveillance and screening include:
- Initial transthoracic echocardiogram (TTE) to assess aortic diameters at several levels
- Computed tomography (CT) or cardiac magnetic resonance (CMR) imaging when the diameter of the aorta exceeds 45 mm
- Serial TTE imaging for patients with a maximum aortic diameter >40 mm, with surveillance every 2-3 years if stability is observed
- These guidelines emphasize the importance of regular monitoring and timely surgical intervention to prevent complications in patients with bicuspid aortic valve-associated aortopathy 1.
From the Research
Aortic Root Dilatation Intervention Thresholds
The threshold for intervention in patients with bicuspid aortic valve (BAV) and aortic root dilatation is a critical consideration. According to the available evidence:
- A maximum aortic diameter of 50 mm is recommended as the threshold for prophylactic surgical aortic repair/replacement in patients with risk factors 2.
- Concomitant aortic surgery is recommended at an aortic diameter of 45 mm in patients with other indications for cardiac surgery, such as aortic valve procedures 2.
- The European Society of Cardiology (ESC) and the joint guidelines of the American College of Cardiology (ACC)/American Heart Association (AHA) recommend elective repair in symptomatic patients with dysfunctional BAV (aortic diameter ≥45 mm) 3.
- In asymptomatic patients with a well-functioning BAV, elective repair is recommended for diameters ≥50 mm, or if the aneurysm is rapidly progressing, or in case of a strong family history of dissection/rupture/sudden death, or with planned pregnancy 3.
Key Considerations
- The risk of dissection/rupture raises significantly with an aneurysm diameter >50 mm 3.
- Diameter is likely not the most reliable predictor of rupture and dissection, and an overly aggressive approach may put some patients with BAV unnecessarily at risk of operative and early mortality 3.
- The use of statins or beta-blockers did not affect the follow-up on the aortic root diameter in patients with BAV who underwent aortic valve replacement (AVR) 4.
- AVR may prevent aortic root dilation in BAV patients whose aortic root diameter at the time of surgery was ≤45 mm 4.